Positive margins with no extraprostatic extension

Britanny56,

Quick answer is that the surgeon cut down into the prostate by mistake, there was cancer there, and when the prostate was pulled out of the body during surgery, a small piece of cancer may have been left in the body.


Here is an overview of margins:

https://medcraveonline.com/unoaj/significance-of-positive-surgical-margin-and-how-to-minimize-in-robotic-radical-prostatectomy.html


Now this is a more technical article, but it has good pictures:

https://documents.cap.org/protocols/cp-malegenital-prostate-radicalprostatectomy-19-4041.pdf

In the above document, page down to page 14 in the document and look at the pictures there.

The top picture shows a man who was pT2 (capsule contained) going into surgery, but the surgeon accidentally cut down into the prostate itself. You can imagine that when the surgeon pulls out the prostate, there will be a little piece of cancer left in the body.

The bottom picture shows a man who was pT3 (not capsule contained, had EPE into prostate capsule or beyond it) going into surgery, and the surgeon did not cut well around the EPE area. Either he cut across the EPE that was sticking out of the capsule, or he cut down through the EPE into the prostate and there was cancer there. Again, when the prostate pieces are pulled out of body, a bit of cancer may remain in the body.

It's odd that both pictures show the final surgical rating as pT2+. I guess that's because in either case the patient still has a small piece of cancer left in them, but otherwise the surgeon got it all? Don't know.


The text under the picture says:

"Recent studies suggest that the Gleason grade or score at a site of margin positivity is correlated with biochemical recurrence. The presence of any pattern 4 or 5 in tumor at a margin doubled the risk of PSA recurrence compared to only Gleason pattern 3 at margin."

In my first pathology in 2012, the pathologist found no EPE (so pT2), saw a margin+, but did not make note of the Gleason of the tissue at my margin.

So, in 2013, I got the world-renowned pathologist J. Epstein at Johns Hopkins to do a second path. Part of his report said:

"Right lateral margin focally involved by prostatic adenocarcinoma, gleason score 3 + 3 = 6, 3mm, intraprostatic incision. The tumor is organ confined elsewhere (pT2+)".

I would suggest you find out what the cancer grade was at the positive margin. It may help you decide the timing and how aggressive to be on future secondary treatments, if any. I think Epstein charges a couple hundred dollars. He's pretty fast in turn-around (or was in 2013, at least).

Hope this helps.

Robert

Brittany, here is a link to the page for Dr. Epstein. I see no specific reason why you could not get the slides sent over from France to Dr. Epstein.

https://pathology.jhu.edu/patient-care/second-opinions/send

Yes, we are near Vannes in Brittany 🙂. Thanks for your advice - this is all so overwhelming. He had the RP just 4 weeks ago and has very severe incontinence - which is not an outcome we were led to expect at all, so good to know about the radiation. There is a very good hospital in Paris that previously gave us a second opinion on the need for surgery. I’ll try to give you a quick sketch of his situation;

February 2020 benign pituitary macroadenoma left his pituitary gland completely crushed (and caused permanent optical nerve damage). From February 2020 onwards, he started taking various synthetic hormones as his body no longer produces them. Amongst the hormones was testosterone…. We now know that he should have had a PSA done before starting the synthetic testosterone and every 3 months after. In February of this year, he turned 50 and his endocrinologist prescribed a PSA test as part of routine testing for a 50 year old. It came in at 5.7. A scan showed two tumours, confirmed by biopsy - Gleason 7(3+4) plus perineural invasion. He had DaVinci surgery 4 weeks ago and the surgeon said everything went fine and that he had gotten it all…. The follow-up is really atrocious- zero psychological support, a page of instructions for Kegel exercises and an appointment to see the surgeon again 6 weeks after the operation. We really feel like we were sold a pup - the surgeon kept talking about a 90% success rate for total continence and sexual recovery with the robotic surgery. We were expecting incontinence of a few drops from time to time, not full-on nappies!! We have contacted the clinic a few times with questions, but we’re clearly annoying them and the surgeon just doesn’t want to know until the 6 week appointment. Ok, I know he wants to wait for the 6 week PSA test, but still…. At this point we’re both just exhausted and trying to hide the strain from our 8 and 9 year old 😟

Thanks for answering. You have at least given me some leads and some answers.

As a surgeons gain experience their percentages of positive margings due to error decrease--the majority are not errors, but rather cuts that anatomically could not safely have been made any wider, because they would have cut into adjacent structure, e.g. too high in the bladder neck, compromising function.

What was his final staging in the path report? If the only finding is a positive margin, it will be pT2 or pT2 R1; if the only finding is EPE, it will be pT3a or pT3a R1.

Djini

It sounds as if your husband has pT2+ psm. That does NOT necessarily mean cancer is still inside his body.

Does the path report give any details about the positive margin(s)?

Djin

Brittany56 said...
It mentions focally positive margins at the apex and mid left third. No dimensions or Gleason score.

Of course margin (singular) would have been better, but "focal" is the best adjective (as opposed to non-focal, or, worse, extensive. Small positive margins do not always pose a risk. You don't know that this was surgeon error.

Djin

Oh that’s good news